Fighting covid19 on the Front Line

Fighting COVID-19 on the Front Line i
An Aid to the Management of COVID-19 in Bangladesh:
“Lessons from the Western Experience”
FIGHTING
ON THE
FRONT LINE
4TH
EDITION

Fighting COVID-19 on the Front Line ii
An Aid to the Management of COVID-19 in Bangladesh:
“Lessons from the western experience”
FIGHTING COVID-19 ON THE FRONT LINE
Fourth Edition is published on June 22, 2020
Third Edition- May 30, 2020
Second Edition - May 10, 2020
First Edition - May 2, 2020
This guidebook is available free for download and
distributing from the following website (also future updates)
shakilfarid.com/covid19
Disclaimer: This guideline is compiled with available information online and contains
widely practiced strategies to mitigate COVID-19. The information is an aid only and
should be tailored according to the local facilities available. The medical information
is provided without any warranties, express or implied.
All content belongs to the respective copyright owners.

Fighting COVID-19 on the Front Line iii
PREFACE
Throughout the world, health authorities are facing unprecedented difficulties in
dealing with the current COVID-19 crisis. Authorities in Bangladesh have already
formulated robust national guidelines with the help of local experts. This handout is a
small effort by some highly motivated Bangladeshi doctors living in the UK and USA
to supplement local guidelines in Bangladesh. This will hopefully enable local experts
in Bangladesh to be kept updated about local treatment protocols worldwide for this
difficult group of patients. In the absence of evidence for specific drug therapy,
mostly supportive treatment is provided throughout world. Specific drug therapy is
provided to only a select group of patients who are enrolled within a clinical trial. This
document has been edited by two very experienced and well-respected Bangladeshi
editors in order to make it more relevant for Bangladeshi doctors. We are very
grateful to our authors for giving their valuable time despite being completely
inundated with work during this pandemic. Most of the materials are adapted from
the most recent national guidelines in the UK (NHS England, NICE, NHS
Improvement, UK Royal Colleges, Public health England, WHO, CDC, Trust
Intranets) and modified for Bangladesh. This handout will be updated regularly as we
learn more about the disease and the guidelines get updated.
Preface to 4th
Edition: The 4th edition adds a new chapter (management of COVID at
Upazilla and district level hospitals) and has significant changes to some chapters
and inclusion of updated information. The evidence chapter has changed
significantly based on emerging evidence.
On behalf of the authors
Dr Shakil Farid MBBS (SSMC), FCPS, MRCS Ed, FRCS (C-Th), MBA (Heath Executive)
Consultant Cardiac Surgeon, Oxford University Hospitals NHS Trust. Oxford, United Kingdom
Website: http://shakilfarid.com Correspondence: shakil.farid74@gmail.com
22nd
of June 2020

Fighting COVID-19 on the Front Line iv
INTERNATIONAL EDITORS
Dr Shakil Farid FCPS, MRCSEd, FRCS(C-Th), MBA
Consultant Cardiac Surgeon with special interest in Aortic Surgery
Oxford University Hospitals NHS Foundation Trust, UK.
Dr Zahed Ikram MRCP, FRCP
Consultant in Geriatric Medicine
Western Sussex Hospitals NHS Trust, UK.
Dr Tasbirul Islam MD, MRCP(UK), FRCP, FCCP
Clinical Associate Professor, Indiana University School of Medicine.,
Medical Director, Division of Pulmonary & Critical care medicine
Indiana University Arnett Hospital, USA.
EDITORS FROM BANGLADESH
Prof. Dr Mohammad Azizul Kahhar MRCP (UK), FCPS
Professor of Medicine
Anwer Khan Modern Medical College & Hospital.
Dhanmondi, Dhaka, Bangladesh.
Prof. Dr Towhidul Alam FCPS, FRCS
Chairman, Department of Surgery
Bangabandhu Sheikh Mujib Medical University (BSMMU)
President, Society of Surgeons of Bangladesh
Dhaka, Bangladesh.

Fighting COVID-19 on the Front Line v
Our little effort is dedicated to Dr Abdul Mabud Chowdhury (Faisal) (CMC) and all the
other front-line health care workers who died on the line of duty. Dr Faisal was a dear friend
of the authors of this book. He was a Consultant Urologist at Homerton University Hospitals.
He died of COVID-19 few weeks after raising concerns about the lack of PPE to the UK
government. He was a great humanitarian, leader and visionary. He will be missed by all of
us.

Fighting COVID-19 on the Front Line vi
A tribute to the unsung heroes
Bangladeshi Doctors Who Lost their lives in Covid-19
Moinuddin Ahmed
Assistant Professor,
Medicine,Sylhet Osmani
Medical
(Died April 15)
Md Moniruzzaman
Professor, Hematology
(Died May 3)
Anisur Rahman
Principal, Northern
Medical College
(Covid Symptom
(died May 11)
Abul Mokarim Md
Mohsin Uddin
Radiologist,
Ibne Sina Hospital
(Died May 12)
Dr. Mir Mahbubur
Rahman
Professor of Surgery
Sylhet MAGOMCH
(Died May 12)
Md. Azizur Rahman
Former MD Titas Gas
(Died May 18)
Sarowar Ibn Abdul
Aziz
GP, Lalbag
(Died May18)
M A Matin
Former ADGHS
(Covid Symptom
died May 22)
Kazi Dilruba
Gynaecologist
(Died May 22)
S M Jafar Hossain
Chittagram Ma o Shishu
Hospital
(Died May 25)
Amina Khan
Retd Senior Consultant
of Gynecology
(Died May 26)
Abdur Rahman
Senior Consultant
(Anesthesia)
(Died withCovid Symptom
May 26)
Md. Mosharraf
Hossain
Retd Professor of
Orthropedics
Sher-e-Bangla MCH
(Died May 27)
Capt (retd) A FM
Saidul Islam
Retired Physician
(Died May 28)
Wahiduzzaman
Akhand
Consultant, Respiratory
Medicine
(Died May 31)
Monzur Rashid
Chowdhury
Former Consultant,
Urology, DMCH
(Died June 2)
A S M Ehsanul
Karim Head of the
Department of Medicine,
Marine City Medical
college
(Died June 3)
Md. Mohiuddin
Professor,Microbiology
Ibrahim Medical College
(Died June 3)
K M Wahidul Haque
Retd Officer DGHS
(Died June 3)
Habibur Rahman
Retd Professor Forensic
Medicine
(Died June 4)
Muhidul Hasan
EMO Chattagram
Medical College
(Died June 4)
N I Khan
Former Professor,
Medicine, Dhaka Medical
College
(Died June 4)
Ehsanul Kabir
Chowdhury
Former UHFPO
(Died June 4)
S A M Golam Kibria
Retd Chairman Urology
BSMMU & Former
president, BCPS
(Died June 5)
Abul Kashem Khan
Former Health
Officer,DEPZ
(Died with Covid
symptomJune 6)
Mirza Nazim Uddin
Chief of ICU & Director,
Medical Services, Square
Hospital
(Died June 7)
Razia Sultana
Retd Govt officer
(Died June 8)
Shakhawat Hossain
Consultant (Anesthesia)
LabAid Hospital
(Died June 8)
Anowar Hossain
Chairman, Rahat
Anowar Hospital
(Died June 9)
Jalilur Rahman
Senior Consultant
(Anesthesia), Impulse
Hospital
(Died June 9)

Fighting COVID-19 on the Front Line vii
Tanzila Rahman
Senior Medical Officer,
Meri Stops Clinic
(Died June 10)
Gazi Jahirul Hasan
Professor, Padeatric
Surgery, BSMMU
(Died June 12)
Mahmud Monowar
Assistant Professor,
Cardiology, NICVD
(Died June 12)
A K M Fazlul Haq
Associate Professor,
Opthalmology, Sikder
Women’s MCH
(Died June 12)
Arif Hasan
General Practitioner
(Died June 12)
Mohammad Sazzad
Hossain
Head of ICU, BRB
Hospital
(Died June 13)
Sadekur Rahman
General Practitioner
(Died June 14)
Nazrul Islam
Dental Surgeon and
Former DGHS
(Died June 14)
Rezaul Karim
Former Professor of
Surgery CMCH & Vice
Chancellor, USTC
(Died June 15)
Toufiqunnesa
Former Health Officer
BCIC
(Died June 15)
A K M Muhibur
Rahman
Professor of Medicine
Former Director,
Suhrawardy Hospital
(Died June 1)
Md. Ashrafuzzaman
Retd Associate
Professor of plastic
surgery, DMCH
(Died June 17)
Md. Shah Abdul Ahad
Former Director, Abdur
Rahim Medical College
(Died June 17)
Nurul Hoq
Seior Medical Officer
Chattagram Metropoilitan
Hospital
(Died June 17)
Rafiqul Haider Liton
Endocrinologist, Enam
Medical College
(Died June 18)
Emdadullah Khan
Senior consultant,
Dermatolgy, Barishal Sher
e Bangla MC
(Died June 19)
Shafiqul Islam
1st batch of SSMC
(Died June 20)
Mujibar Rahman Ripon
Associate Professor,
Dept of Pediatrics,
Central Medical College
(Died June 20)
Bazlur Rahman
Surgeon, Impulse Hospital
(Died June 20)
Sunil Kumar Sarkar
Retd Cardiac Surgeon,
NICVD (Died June 20)
Lalit Kumar Dutta,
ENT specialist,
Chottogram
(Died June 21)
Source: Prothom Alo (18/6/2020), The Daily Star (18/6/2020), Corona Virus Global Update and Response,
বাংলােদশ েমিডকয্াল সংবাদ
List updated on 21/6/2020 by Dr Samia Mubin and Dr Sajid Muhaimin Choudhury
“Our Nation owes a debt to its fallen heroes that we can never fully repay, but we
can honor their sacrifice, and we must” – Barack Obama on Fallen Heroes

Fighting COVID-19 on the Front Line viii
ADVISORY BOARD
National Professor Shahla Khatun
Prof of Gynaecology and Obstetrics, Chairman, Green Life Hospital
Prof A K Azad Khan
Prof of Gastroenterology, President, Diabetic Association of Bangladesh
Prof. Kanak Kanti Barua
Ex Professor and Chairman, Dept of Neurosurgery
Vice Chancellor, Bangabandhu Sk. Mujib Medical University, Dhaka.
Prof M. Nazrul Islam
UGC Prof of Cardiology,
Vice Chancellor, Bangabandhu Sk. Mujib Medical University, Dhaka.
Prof Syed Atiqul Haq
Prof of Rheumatology, Bangabandhu Sk. Mujib Medical University, Dhaka.
President, Asia Pacific League of Associations for Rheumatology,
President, Bangladesh Rheumatology Society.
Maj Gen Md Azizul Islam
Consultant physician General, Prof of Medicine and Oncologist
Bangladesh Armed Forces, Ministry of Defence, Dhaka Cantonment.
Prof Liaquat Ali
Former Vice Chancellor, Bangladesh University of Health Sciences.
Prof Mujibur Rahman
Prof and Head of dept of Medicine, Dhaka Medical College and Hospital, Dhaka.
Controller of Examinations, BCPS.
Prof Abdul Wadud Chowdhury
Prof and Head dept of Cardiology, Dhaka medical college and Hospital, Dhaka.
Prof Ferdousi Begum
Prof of Obstetrics and Gynaecology, Ibrahim Medical College, Dhaka.
President, South Asian Federation of Obstetrics and Gynaecology.
Prof Robed Amin
Prof of Medicine, Dhaka medical college and Hospital, Dhaka.

Fighting COVID-19 on the Front Line ix
List of Contributors:
Dr Moshfiq Abeer MRCP(UK), MRCP (Resp Med)
Consultant Respiratory Physician, Hull and Yorkshire Hospital, UK.
Prof AKM Akhtaruzzaman MBBS, DA, MD
Professor and Chairman, Department of Anaesthesia, Analgesia and Intensive Care Medicine, Bangabandhu
Sheikh Mujib Medical University, Dhaka, Bangladesh
Dr Kazi Asif Adnan MBBS, MRCP(UK)
Consultant Interventional Cardiologist, Sandwell and West Birmingham Hospitals NHS Trust, UK
Prof Shafi Ahmed PhD, FRCS (General Surgery)
Prof of Surgery, Laparoscopic Colorectal Surgeon, The Royal London Hospital, UK.
Dr Chowdhury H Ahsan MRCP, MD, Ph.D., FSCAI
Clinical Professor of Medicine, Director, Cardiac Catheterization and Intervention
Director, Cardiovascular Research University Medical Center, Las Vegas, Nevada, USA
Dr Nashid Noor Alam MBBS MRCP MRCP (Geriatric Medicine) FRCP
Consultant Physician/Geriatrician/Stroke Physician, Northern Health and Social Care Trust, Northern Ireland, UK.
Dr Basher M Atiquzzaman, MD
Faculty, College of Medicine, University of Central Florida, Consultant, Gastroenterology and Hepatology,
Digestive and Liver Center of Florida Orlando, Florida
Dr Iffat Azim MBBS MPH
General Practitioner, Harley Street Health Centre, London
Prof Tipu Zahed Aziz F.Med.Sci.
Prof of Neurosurgery, Nuffield Department of Surgery, Oxford University Hospitals NHS Foundation Trust, UK.
Dr Snehashish Banik MRCP(UK), FHEA(UK)
Consultant Acute Medicine and Acute Stroke, Aberdeen Royal Infirmary, NHS Grampian, Scotland.
Director, Academic Foundation Program, North Scotland Deanery.
Dr Verona Beckles Bsc, MBBS, MSc, MRCS(Ed), FRCS(Ed)
Consultant, Trauma & Orth, Queen’s Hospital, Barking, Havering and Redbridge NHS Foundation Trust, UK.
Dr Sarah Choudhury MBBS. MRCP (Acute medicine), FRCP, DIP MED SC (Medical Toxicology)
Consultant in Acute Medicine, Northwest Anglia NHS foundation Trust, UK.
Dr Shakil Farid MBBS FCPS(Surgery) MRCSEd, FRCS(C-Th), MBA (Health Executive)
Consultant Cardiac Surgeon with special interest in Aortic Surgery, Oxford University Hospitals, UK.
Prof Sheikh Abdul Fattah MBBS, FCPS
Dept of Medicine, Shaheed Tajuddin Ahmed Medical College Hospital, Gazipur, Dhaka, Bangladesh.
Dr S A Haider MBBS MRCP (UK)
Consultant Physician, Geriatrician and Stroke Physician, King’s Mill Hospital, Sherwood Forest Hospital NHS
Foundation Trust, Birmingham, UK.
Dr Farzana Haque MBBS MRCP(UK)

Fighting COVID-19 on the Front Line x
Clinical Research Fellow, Hull and York Medical School, Specialty Registrar Oncology, Hull Teaching Hospital,
UK.
Dr Tahmina Haque MBBS MRCPsych Dip in Psychiatry
Consultant Psychiatrist, Leeds and York Partnership NHS Foundation Trust, UK.
Dr Omar Hasan MD FACC
Attending interventional Cardiologist, Clinical Assistant Prof Hackensack University Medical Center, NJ, USA.
Dr Mehedi Hasan MBBS, FCPS, MRCP, FRCPath
Consultant Haematologist, Lister Hospital, North and East Hertfordshire NHS Trust, UK.
Dr Nayeem Hasan MBBS
Specialty Doctor, Acute Medicine, West Suffolk Hospital NHS Foundation Trust, UK.
Dr Tanjina Hossain MD, FACE
Associate Professor, Endocrinology, Green Life Medical College, Dhaka, Bangladesh.
Dr. Samiul Huda MBBS
Assistant Surgeon, USC Choto Bhakla, Goalanda, Rajbari, Bangladesh.
Dr Sadeka Shahani MD
Attending endocrinologist, Wellstar Health, Marietta, Georgia, USA
Dr Syed Shahreer Huq MBBS MRCP (Resp Med) FRCP RPSGT
Somnologist, Consultant Respiratory Physician, University Hospital Birmingham NHS foundation Trust, UK
Dr Zahed Ikram MBBS, MRCP, FRCP
Consultant in Geriatric Medicine, Western Sussex Hospitals NHS Trust, UK.
Dr Javed Imam MBBS, MRCP
Consultant, Stroke Medicine, West Suffolk Hospital NHS Foundation Trust, UK.
Dr Tasbirul Islam MD, MRCP(UK), FRCP, FCCP
Clinical Associate Professor, Indiana University School of Medicine., Medical Director, Indiana University Arnett
Hospital, USA.
Dr Taufiq Islam MBBS, MRCS, FCPS
Surgical Assistant, Division of Thoracic Surgery, Royal Alexandra Hospital, Edmonton, AB, Canada.
Dr Bandana Rajbhandari Joshi MBBS FRCPCH
Consultant Community Paediatrician, Dip Neurodisability, St Mary’s Hospital, Northamptonshire Healthcare NHS
Foundation Trust, UK
Dr Zahed Khan MRCP (medicine) MRCP (Medical oncology)
Consultant Medical Oncologist, Clatterbridge Cancer Centre NHFT, UK
Dr Jeenat Khan MBBS
Specialty Doctor, Geriatric Medicine & Stroke, South Eastern Health and Social Care Trust, Northern Ireland, UK.
Dr Rahila Khan MBBS, MRCOG, MD
Consultant, Obstetrician and Gynaecologist, Lead in Maternal Medicine and Diabetic Pregnancy, Worthing
Hospital, UK.
Dr Samia Mubin MBBS FCPS MRCS

Fighting COVID-19 on the Front Line xi
Associate Professor of Surgery, BSMMU, Dhaka, Bangladesh.
Dr Quazi Rezina Naquib MBBS, DCH, MRCPCH
Paediatrician, East Kent Hospitals University Hospitals Foundation Trust, Kent, UK.
Dr Quazi Selina Naquib MBBS, MRCOG, DFFP
Obstetrician and Gynaecologist, Whips Cross University Hospital, Barts Health NHS Trust. London.
Dr Ashrafun Nessa MRCS, MCPS FCPS
Specialty Registrar, General Surgery, Aberdeen Royal Infirmary, NHS Grampian, Scotland, UK.
Dr Sharmin Afroz Panna MBBS MSc (Psychiatry)
Specialty Doctor, Specialist Secure Unit, Mental Health, Merseycare NHS Foundation Trust, UK.
Dr Jhumur Pati MBBS FRCS FRCS (Urology)
Consultant Urological Surgeon, Homerton University Hospital and Barts Health NHS Trust, UK.
Dr Shama Parveen MBBS MRCPsych
Consultant Psychiatrist in Intellectual Disability, Sussex Partnership Foundation NHS Trust, UK.
Dr Indrajit Prasad FCPS, MD, FACE
Associate Professor, Endocrinology, Dhaka Medical College and Hospital
Dr Sabyasachi Roy MBBS
Internal Medicine Trainee, Royal Cornwall Hospitals NHS Trust, UK.
Dr Shahriar MD Sadek MBBS MRCSEd, FRCS
Consultant General and Colorectal Surgeon, Royal London Hospital, Barts Health NHS Foundation Trust, UK.
Dr Lunik Rollei Sarder MBBS MRCEM FRCEM
Emergency Medicine Consultant, Queen’s Hospital, BHR University Hospitals NHS Trust, UK.
Dr Ahsan Habib Sowdagar LRCP, LMSSA, LRCS, DCH, PG. Dip. Dermatology
GPwSI Dermatology, Community Dermatology Services,
Homerton University Hospital NHS Trust, Hackney, London. United Kingdom.
Dr Rana Sayeed MBBS MRCP (UK) FRCS (CTh) PhD
Consultant Cardiac Surgeon and Clinical Lead, Oxford University Hospitals NHS Foundation Trust, UK.
Dr Kazi Fatema Shahadat MBBS, MRCGP
GP Partner and Trainer, Betts Avenue Medical Centre, Newcastle, UK.
Dr Afroza Shameen MMedSci (UK), MBBS(DU)
Specialty Doctor, Accident and Emergency, Doncaster Royal Infirmary, Doncaster and Bassetlaw Teaching
Hospitals NHS Foundation Trust, UK.
Dr Arifa Siddika MBBS, MRCS, FRCS (Gen and Colorectal Surg)
Consultant, General and Colorectal Surgery, Homerton University Hospital, London, UK.
Dr Quazi Mahmud Siddiqui MBBS, FCPS, FRCA
Consultant Anaesthetist, Rockhampton Base Hospital, University of Queensland Rural Medical School,
Queensland, Australia
Dr Tasmin Sultana MBBS
Specialty Doctor, Trauma & Ortho, Queen’s Hospital, Havering and Redbridge NHS Foundation Trust, UK.

Fighting COVID-19 on the Front Line xii
Dr Farhana Tasneem Rimi MBBS MRCP
Clinical Research Fellow (Cardio), University Hospital Leicester NHS Trust, UK, Clinical PhD student,
Cadiovascular Science and Sports Physiology, Loughborough University, UK.
Dr Muhammad Shamse Tabriz MD
Consultant, Infectious Disease, Advocate Christ Medical Center, Clinical Associate Prof of Medicine, University of
Illinois, Chicago, USA.
Dr Md Zaker Ullah MBBS, FRCSEd, FRCS (Gen and Breast Surg)
Consultant General and Oncoplastic Breast Surgeon, Whipps Cross University Hospital, Barts Health NHS Trust,
UK.
Dr Nihad Yasmin MD Board certified (Internal medicine and Rheumatology)
Attending Rheumatologist, Advocate Aurora Health, Wisconsin, USA.

Fighting COVID-19 on the Front Line xiii
Acknowledgements
We are very grateful to Dr Sajid Muhaimin Choudhury (Assistant Professor,
Department of Electrical and Electronic Engineering, BUET; sajid.buet.ac.bd) for
compiling and designing the whole document . We are also grateful to Dr Kaiser
Nasrullah Khan, Dr Sabyasachi Roy (and other members of the SSMC Alumni
Association, UK) for their help in initiating the process of writing this book.
Special thanks to Dr Samia Mubin and Dr Arifa Siddika for coordinating the cross-
country communications and to Dr Parul Akhtar for collecting the author details.
We are also grateful to the following experts for their advice with the preparation of
the manuscript:
Dr Andrew Johnson, Consultant Intensivist, Oxford University hospitals, Dr Katie
Jeffery, Director, Nuffield dept of infectious diseases and Dr Anny Sykes,
Consultant Respiratory physician, Oxford University Hospitals NHS Trusts.
The cover image is taken from pixabay.com (by @enriquelopezgarre).

Fighting COVID-19 on the Front Line xiv
CONTENTS
1. COVID19 – KEY RECOMMENDATIONS FOR BANGLADESH........................................................................ 17
2. DIAGNOSIS AND MEDICAL MANAGEMENT ............................................................................................. 20
2.1 TESTS FOR COVID-19 ................................................................................................................................. 20
2.2 THE ROLE OF CHEST IMAGING IN COVID-19 PATIENTS........................................................................................25
2.3 KEEPING PATIENTS OUT OF HOSPITAL............................................................................................................... 28
2.4 COVID-19 SEVERITY SCORING TOOLS AND NON-ICU MANAGEMENT ...................................................................31
2.5 EMERGENCY DEPARTMENT TRIAGE GUIDELINE FOR SUSPECTED COVID-19 PATIENTS...............................................38
2.6 MANAGEMENT OF C19 AT UPAZILLA AND DISTRICT LEVEL...................................................................................42
2.7 COVID-19 ISOLATION AND DISCHARGE PATHWAYS............................................................................................ 47
2.8 ROLE OF ANTIMICROBIALS IN COVID-19........................................................................................................... 48
2.9 EVIDENCE FOR SPECIFIC PHARMACOLOGICAL TREATMENT FOR COVID-19..............................................................53
3.0 THROMBOPROPHYLAXIS AND MANAGEMENT OF COAGULOPATHY IN COVID-19......................................................64
3. OXYGEN: THE MAIN THERAPY FOR MANAGEMENT OF COVID................................................................. 69
3.1 HOSPITAL OXYGEN SUPPLY:........................................................................................................................... 69
3.2 OXYGEN DELIVERY SYSTEMS........................................................................................................................... 74
3.3 PRINCIPLES OF NIV AND CPAP FOR “NON-INTENSIVISTS” ..................................................................................76
3.4 ICU MANAGEMENT STRATEGIES .................................................................................................................... 82
3.5 ANAESTHESIA AND COVID-19 ...................................................................................................................... 96
3.6 GUIDANCE ON CPR IN ACUTE HOSPITAL SETTINGS............................................................................................103
4. INFECTION ............................................................................................................................................106
4.1 INFECTION CONTROL.................................................................................................................................. 106
4.2 CURRENT RECOMMENDATIONS FOR PERSONAL PROTECTIVE EQUIPMENT (PPE) IN COVID-19: ...............................116
4.3 PROTECTION FOR HEALTH CARE WORKERS AND PRECAUTIONS AFTER INADVERTENT EXPOSURE..................................124
4.4 EXTENDED USE OR RE-USE OF N-95/FFP3 AND REUSABLE GOWNS: ....................................................................127
4.5 FIT TEST FOR FFP2/3 AND N95 .................................................................................................................. 129
4.6 REDUCING THE RISK OF TRANSMISSION – DISINFECTION ....................................................................................130
5. MEDICAL SPECIALTIES............................................................................................................................135
5.1 HEART DISEASE AND COVID-19 .................................................................................................................. 135
5.2 KIDNEYDISEASE ANDCOVID-19....................................................................................................................... 145
5.3 ELDERLY PATIENTS AND COVID-19 .............................................................................................................. 152
5.4 DIABETES MELLITUS AND COVID-19............................................................................................................ 159
5.5 NUTRITION MANAGEMENT AND PHYSICAL ACTIVITY IN COVID19 AND DIABETES ....................................................167
5.6 DIGESTIVE AND LIVER MANIFESTATIONS OF COVID 19 ....................................................................................169
5.7 RHEUMATOLOGY AND COVID-19................................................................................................................ 173
5.8 NEUROLOGY AND COVID-19...................................................................................................................... 175
5.9 CUTANEOUS ERUPTIONS ASSOCIATED WITH COVID 19.....................................................................................178
6.SURGERY AND ONCOLOGY .....................................................................................................................182
6.1 SURGERY AND COVID-19 .......................................................................................................................... 182
6.2 THORACIC SURGERY, LUNG CANCER AND COVID 19 .......................................................................................196
6.3 CANCER AND COVID-19............................................................................................................................ 202
6.4 BREAST CANCER AND COVID-19 ................................................................................................................. 206
BREAST SERVICE PROVISION.................................................................................................................................. 206

Fighting COVID-19 on the Front Line xv
7. PAEDIATRICS AND GYNAECOLOGY.........................................................................................................210
7.1 PREGNANCY WITH CONFIRMED AND SUSPECTED COVID-19..............................................................................210
7.2 PAEDIATRICS / NEONATES AND COVID-19.................................................................................................... 216
7.3 CHILDHOOD IMMUNISATION DURING COVID19 PANDEMIC..............................................................................226
8. MENTAL HEALTH...................................................................................................................................228
8.1 MENTAL HEALTH AND COVID-19................................................................................................................ 228
8.2 MENTAL HEALTH OF HEALTH CARE PROFESSIONALS AND COVID-19....................................................................230
MISCELLANEOUS.......................................................................................................................................232
I. RELOCATION OF RESOURCES ........................................................................................................................ 232
II. PRACTICAL PROBLEMS IN BANGLADESH THAT NEEDS ADDRESSING: ......................................................................234
III. NATIONAL EARLY WARNING SCORE (NEWS) ................................................................................................. 235
IV. SOME FREQUENTLY ASKED QUESTIONS........................................................................................................... 237
V. FUTURE DIRECTIONS................................................................................................................................... 251

Fighting COVID-19 on the Front Line xvi
Abbreviation Elaboration
ARDS Acute respiratory distress syndrome
AKI Acute kidney injury
AGP Aerosol Generating Procedure
BiPAP Bilevel Positive Airway Pressure
CPAP Continuous Positive Airway Pressure
CPK Creatine Phosphokinase
CQ Chloroquine
DNACPR Do Not Attempt Cardio Pulmonary Resuscitation
EBUS Endobronchial Ultrasound
EPAP Expiratory positive airway pressure
ECMO Extra Corporeal Membrane Oxygenation
EMG Electromyography
FiO2 Fraction of inspired Oxygen
HCQ Hydroxychloroquine
HFNC High flow nasal cannula
IPAP Inspiratory positive airway pressure
IADL Instrumental Activities of Daily Living
ITU/ICU Intensive Therapy Unit/Intesive Care Unit
LLETZ Large Loop Excision of Transition Zone
LPM Litre per minute
MDT Multidisciplinary Team
MTX Methotrexate
MVA Manual Vacuum Aspiration
NPO Nil by mouth
NMBA Neuromuscular blocking agent
NCS Nerve Conduction Study
NIV Non Invasive Ventilation
NRB Non Rebreather Mask
PARP Poly (ADP-Ribose)Polymerase
PPE Personal protective equipment
PNRB Partial non breather
PSA Pressure swing adsorption
PCR Polymerase Chain Reaction
RAAS Richmond Agitation Sedation Scale
RRT Renal Replacement Therapy
SABR Stereotactic Ablative Radiotherapy
SCID Severe Combined Immunodeficiency
SOB Shortness of breath
UOP Urinary Output
URT Upper Respiratory Tract
VATS Video Assisted Thoracoscopic Surgery
VQ Ventilation Perfusion
VTE Venous Thromboembolism
IV Invasive Ventilation

Fighting COVID-19 on the Front Line 17
1. COVID19 – KEY RECOMMENDATIONS FOR
BANGLADESH
SYSTEM RECOMMENDATIONS
• Focus of management is supportive care. The vast majority of patients
recover without any intervention and can be managed at home.
• The incidence of false negative for RT-PCR is up to 30%, so every suspected
case of COVID should be treated as positive unless proven otherwise or until
the results of a repeat test is available.
• It is vital that oxygen supply should be increased in the country, and that
all major hospitals should have centrally distributed oxygen. Oxygen is the
best treatment for Covid-19 pneumonia. A cost effective and rapid way to
install central oxygen in all major hospitals is presented in our OXYGEN
chapter.
• Consider trial of awake proning, nasal cannula, Venturi mask, Non-
rebreather mask, High Flow Nasal Cannula (HFNC), Non Invasive
Ventilation (NIV), before Invasive-mechanical ventilation (IV). The
objective is to AVOID mechanical ventilation – no healthcare system can cope
with large numbers of patients requiring IV, and outcomes are very poor.
• For HNFC and NIV (CPAP and BIPAP), create High Dependency Units or
Wards, staffed with junior doctors & nurses up skilled to use these machines,
and well stocked with level 2 PPE.
• All healthcare facilities with central oxygen supply should be identified
and used to care for Covid-19 patients requiring oxygen
supplementation. Operating theatres and surgical recovery areas should
be considered for conversion to ICU beds.
• Use the National Early Warning Score (NEWS) to identify a deteriorating
patient. This is an aggregate score using respiration rate, oxygen saturation,
systolic blood pressure, pulse rate, level of consciousness or new confusion,
temperature, and has trigger points which will lead to a nurse calling a doctor
or to a junior doctor calling a senior doctor for help or advice.

• All hospitals should accept COVID 19 patients who require hospitalization.
This can be done by having RED (COVID confirmed), AMBER (suspected
COVID) and GREEN (NON-COVID) zones in each hospital. Aerosol
generating procedures-AGPs (ICU/endoscopy suites/theatres etc.)
should be treated as RED zone. TRIAGE is crucial to identify the
appropriate patient for each zone.
• Strong collaboration is needed between the government and private
healthcare providers in order to ensure access to treatment for all the COVID
patients needing hospitalization.
DRUG RECOMMENDATIONS
• Evidence for pharmacological therapy is emerging. The largest RCT
RECOVERY Trial has shown that low dose dexamethasone significantly
reduces mortality in severe and critically ill patients needing
supplemental oxygen therapy/ventilation, but it is not useful in patients
not requiring oxygen therapy. Some other drugs may be used in specific
situations, but only under close observation.
• The use of Hydroxychloroquine (HCQ) and Chloroquine is discouraged,
as there is evidence of its efficacy and there are evidences of increased
mortality in Covid-19 when these drugs are used alone or in combination with
azithromycin.
• The use of Favipiravir is not recommended. There is no evidence that it
works. This drug has been reported to prolong the QT interval, as do
HCQ, Chloroquine and Azithromycin, and as these drugs are being used
in combination in Bangladesh, this is likely to further increase toxicity.
• IL-6 inhibitors are only to be used in Cytokine Release Syndrome, provided
bacterial, fungal and other infections (TB, Hepatitis B) have been excluded.
• Convalescent Plasma is being widely used but is as yet of unproven benefit,
however the preliminary results are encouraging. If it’s used antibody titre
must be checked (titre 1 in 160) and no more than two units should be
transfused.

• There is no evidence that Ivermectin, alone or in combination with
Doxycycline, has any effect on Covid-19.
• Remdesivir may be used for Covid-19 pneumonia requiring oxygen
supplementation to accelerate recovery, but there is no evidence that it has a
mortality benefit. It has not been shown to benefit other categories of patients.
If used, it should be started 6-12 days after onset of illness (in patients
requiring supplemental oxygen).
• Use thromboprophylaxis for all hospitalized patient with COVID 19.
• Antimicrobials (antibiotics and antifungals) are only indicated in severe cases,
depending on clinical suspicion, laboratory confirmation or radiological
evidence of coinfection or superinfection with bacteria or fungus.
Severity Profile of COVID-19
Require ICU care
Require essential care
(O2 and supportive therapy)
Ambulatory Care
5%
15%
80%
Figure 1: Severity profile of COVID19. Figure form Wu et al 2020
2

2. DIAGNOSIS AND MEDICAL MANAGEMENT
2.1 Tests for COVID-19
Dr Zahed Ikram
Key terms
RNA C19 uses RNA to store its genetic code
Antigen A foreign structure that triggers the immune system
Antibody Protective proteins produced in response to antigens
Sensitivity Ability of a test to give a positive result when it is supposed to be
positive
Specificity Ability of a test to give a negative result when it is supposed to be
negative
POC Point of care testing, done at site with almost immediate results.
Test techniques
Reverse Transcriptase polymerase chain reaction (RT-PCR) Current
standard test for C19. Needs a series of temperature changes.
Reverse Transcriptase Loop mediated Isothermal Amplification (RT-LAMP)
Simple but less developed testing technique. Done at a constant
temperature.
Lateral Flow Immunoassay (LFA) Hand-held single use assays providing
results for an individual patient in as little as 15 minutes.
Enzyme-linked immunosorbent assay (ELISA) Quick and technically
simple assays that are easily read and offer relatively high throughput.
Categories of tests
Tests of viral RNA
Antigen tests
Antibody tests

Tests of viral RNA
1. RT-PCR (current gold standard test)
Site – Nasal and nasopharyngeal swab ± sputum.
Positive result – generally means ongoing infection.
Negative result – could mean a) no current infection b) virus not present at the site of
sampling c) poor quality sampling d) too early or too late in the infection to detect
replicating virus.
Specificity – high.
Sensitivity - moderate.
Ease of testing – complex but well established test, but takes hours to do and much
longer if the sample has to be transported. Result on same day is unlikely.
2. RT-LAMP (alternative to RT-PCR)
Site – Nasal and nasopharyngeal swab ± sputum.
Current ongoing trials as alternative to RT-PCR. Potential for Point of care testing (2-
3 hours).
Tests for viral antigen
This is done by LFA. Antigen assays detect the virus directly without the
amplification steps of RT-PCR and LAMP, and detects current active infection.
Kits are being trialed in USA, Japan and India.
Site - Nasal and nasopharyngeal swab.
Positive result – generally means ongoing infection.
Negative result – needs swab for RT-PCR.
Specificity – high.
Sensitivity – low.
Advantages – done at point of care.
Disadvantages – negative tests have to have repeat swab collection and RT-PCR.

Antibody tests
Detect binding antibodies against spike glycoprotein (S) and Nucleocapsid
phosphoprotein (N). (Neutralising antibody tests currently not approved).
Depending on reagent, IgM, IgG or total antibody may be detected.
POC (point-of-care) tests are done by LFA.
Sample - Usually done on finger-prick blood.
Advantages –
1. Done at POC
2. Result available within 30 minutes
3. Blood draw may be avoided
4. Skilled technicians not required
5. Detects past infection
Disadvantages –
1. Not as accurate as ELISA
2. Not generally useful for detecting current infection
3. Measuring antibody titre is not possible
4. It is unknown whether a positive test means immunity
Laboratory tests are usually done by ELISA.
Sample – blood drawn by venepuncture.
Advantages –
1. Good sensitivity and specificity (depends on kit)
2. Measuring IgG antibody titre is possible (for Convalescent Plasma collection)
3. Detects past infection
Disadvantages –
1. Requires venepuncture
2. Not generally useful for detecting current infection
3. Skilled technicians and expensive machinery is required
4. It is unknown whether a positive test means immunity

Source: Diazyme Laboratories, Inc. (https://archive.is/vkEGJ)

References:
1. Report from the American Society for Microbiology COVID-19 International
Summit, 23 Mar 2020: Value of Diagnostic Testing for SARS–CoV-2/COVID-
19
2. Roche.com
3. Effectiveness of patient-collected swabs for influenza testing. Mayo Clin Proc
87: 548 –554
4. Negative nasopharyngeal and oropharyngeal swab does not rule out COVID-
19. J Clin Microbiol 26 Feb 2020
5. Saliva is more sensitive for SARS-CoV-2 detection in Covid-19 patients than
nasopharyngeal swabs Willey, Fournier, Ko. (not peer reviewed)
6. www.cdc.com. Information for laboratories about COVID-19

2.2 The role of chest imaging in COVID-19 patients
Dr Tasbirul Islam
The threshold for the imaging of patients with potential/confirmed COVID-19
demonstrates a degree of variation globally due to local resources, the published
guidelines of individual learned bodies and sociocultural approaches to imaging.
KEY POINTS:
• CXR or CT scan shouldn’t be used to diagnose COVID-19. Viral testing (RT-
PCR) remains the only specific method of diagnosis.
• Imaging is not indicated in asymptomatic or mild cases.
• CT should be reserved for patient who are critically ill and for when there is
diagnostic uncertainty.
• Normal CXR or CT scan doesn’t exclude COVID-19 (up to 50% patients with
COVID-19 may have normal CT scans, especially on day 0-2 of
commencement of the disease).
• Generally, the findings on chest imaging in COVID-19 are not specific, and
overlap with other infections.
• CXR is insensitive in mild or early COVID-19 infection. Chest-films can be
useful in the follow-up of the disease.
• CT is more sensitive for early parenchymal lung disease, disease
progression, and alternative diagnoses including acute heart failure from
COVID-19 myocardial injury.
• Most common CT features reported are bilateral and subpleural ground
glass opacification, consolidation affecting the lower lobes in first 4-5
days. Crazy-paving pattern might be seen in 4-14 days from symptom
onset.
• Peak radiological abnormalities occurred at around day 10, followed by
gradual regression starting 2 weeks after symptom onset.
• Radiological improvement predating RT-PCR becoming negative in 42%
of patients recovering from COVID-19 pneumonia.
• Negative CT 1 week after symptom onset is reported to have a high
negative predictive value for COVID-19 pneumonia.
• CT is indicated in patients with functional impairment, hypoxemia, or both,
after COVID-19 recovery.
• COVID-19 testing is warranted in patients incidentally found to have findings
suggestive of COVID-19 on a CT scan.
• Daily CXR’s are not indicated in stable intubated patient.

CT chest patterns in COVID-19 patient:
• Multifocal, bilateral, peripheral ground glass pattern (GGO) is the most
common findings.
• Sometimes crazy paving pattern (thickened interlobular and intralobular lines
in combination with a ground glass pattern) found in later stage of the
disease.
o GGO pattern: 88%
o Bilateral involvement: 88%
o Posterior distribution: 80%
o Multi lobar involvement: 79%
o Peripheral distribution: 76%
o Consolidation: 32%
GGO pattern Crazy Paving pattern

CXR patterns in COVID-19 patient:
1.Bilateral peripheral consolidation 2. Ground glass opacity 3. Predominantly bibasal
CXR is insensitive in early stage:
CXR CT chest
Ultrasound chest imaging of COVID-19 patients is not included as it
is not widely available and lack of direct experience in Bangladesh.
Reference:
• Image sources: https://radiologyassistant.nl/chest/lk-jg-1
• Bai HX et all. Performance of radiologist in differentiating COVID-19 from viral pneumonia in
chest CT. Radiology 2020. Published online March 10.
• British Society of Thoracic imaging. Radiology decision tool for suspected COVID-19.
• Ai T et al. Correlation of chest CT and RT-PCR testing in COVID-19 in China. Report of 1014
cases. Published Feb 24.
• Pan F et all. Time course of lung changes on chest CT during recovery from COVID-19
pneumonia. Radiology 2020. Published Feb 19.

2.3 Keeping patients out of hospital
Dr Kazi Fatema Shahadat, Dr Iffat Azim
Why keep patients out of hospital:
 To avoid unnecessary admission and made bed available for sick patient.
 Minimize the health risks to health care worker, patients and wider communities.
 Most patients with COVID-19 can be managed remotely with advice on
symptomatic management and self-isolation.
 Although such consultations can be done by telephone in many cases, video
provides additional visual cues and therapeutic presence
Tools for Remote Assessment:
 Telephone consultations.
 Video consultations - AccuRx, Viber, WhatsApp, Facebook messenger apps
etc. can be used
 Smart watch or smart phone.
 Information can be shared with physician using BP machine, Pulse oximeter,
Thermometer at home.
 Hotline phone number

Red flags symptoms:
 Severe breathlessness or difficulty breathing.
 Pain or pressure in the chest.
 Blue lips or face.
 History suggestive of shock such as cold and clammy with mottled skin, new
confusion, becoming difficult to rouse or significantly reduced urine output.
 Haemoptysis occurs in about 1% of covid-19 patients and seems to be a poor
prognostic symptom.
Urgent hospital transfer

Staying at home and shielding (High Risk group)
You’re strongly advised to stay at home at all times and avoid any face-to-face
contact if you’re clinically extremely vulnerable to protect yourself. This is called
‘shielding’.
Shielding means:
 Do not leave your house.
 Do not attend any gatherings. This includes gatherings of friends and families
in private spaces, for example, family homes, weddings and religious
services.
 Strictly avoid contact with someone who is displaying symptoms of
Coronavirus (COVID-19). These symptoms include high temperature and/or
new and continuous cough.
Living with other people during Self Isolation
 The rest of your household do not need to start shielding themselves, but they
should do what they can to support you in shielding and to carefully follow the
local protocols.
 At home you should:
 Minimise the time spent in shared spaces such as kitchens, bathrooms and
sitting areas, and keep shared spaces well ventilated. Always keep separate
towels for your yourself.
 Keep 2 meters (3 steps) away from people you live with and
encourage them to sleep in a different bed where possible.
Advice for patients with mild to moderate disease who are not hospitalised (Dr
Shaila Nupur, MD):
1. Breathing exercise- take a slow deep breath, go to the bottom of the lungs and
hold it for 10 seconds and then let it out. Do it every hour 10 times.
2. Laying down in prone position.
3. Keep well hydrated.
4. Get out of bed every hour and walk few minutes to prevent blood clot.
References:
 Guidance and standard operating procedures- General Practice in the context of Coronavirus
(COVID-19); Version 2.1 NHS England and NHS Improvement
 Primary care Pathways.co.uk/covid-19/clinical-assessment/pathways
 BMJ (British Medical journal)
 UK guidelines in Practice highlights
 GOV.UK website
 Red Whale GP Update
 www.nice.org.uk/guidance

2.4 COVID-19 severity scoring tools and Non-ICU
Management
Dr Mosfiq Abeer, Dr Farzana Haque, Dr Afroza Shameen, Dr Tasbirul Islam
FBC: Full blood count (same as CBC for Bangladesh), BCP: Biochemical profile (Liver
function test, renal function test, electrolytes, Ca etc.)
Case definition for possible case:
1. Clinical or radiological pneumonia or
2. Acute Respiratory Distress Syndrome or
3. Influenza like illness
CLINICAL ASSESSMENT for those who may require hospital admission
• House in side-room or cohort area and wear personal protective equipment according to local guidance
• History, examination and standard observations (pulse, RR, BP, temperature, pulse oximetry, capillary refill time)
• If not known positive AND requires admission do nasopharyngeal swab
SEVERITY ASSESSMENT
• Consider the following risk factors for mortality:
• Older age group: Mortality high over 60 years
• Co-morbidity: especially cardiac / hypertension, diabetes, COPD/Asthma, current smoker,
obesity
• Immunocompromise: HIV/AIDS, severe malnutrition, Chronic steroid use, Immunosuppressive
medication, ongoing anti-cancer treatment
• Sepsis red flags (see box below) and Severity scoring tool (see box below)
• Severe acute respiratory distress
• Low functional status and / or poor social circumstances
• High risk relative at home and unable to self-isolate (may be unrealistic in pandemic)
CONSIDER the following tests according to comments below and necessity for admission or clinical
decision making:
• FBC, BCP, CRP, Blood Culture (if fever or sepsis or severe illness) before antibiotics- Expect
Lymphopenia, high CRP and AKI
• Chest radiograph for ALL patients needing admission to hospital- Typically patchy ground glass
opacities peripheral, basal and bilateral (unilateral in 25%)
• ECG (Do Troponin if new changes)
• Nasopharyngeal swab (broad-based respiratory PCR)- As sensitivity is not 100%, one negative
swab does NOT rule out COVID. Send a second swab, and sputum, if clinical suspicion high.
• Consider COVID prognostic indicator- D-dimer, ferritin– high values indicate cytokine storm/MAS
• Consider early chest CT/CTPA specially if PE is suspected- ground-glass opacities (GGO):
bilateral, basal, peripheral; sensitivity around 80%
POTENTIAL COMPLICATIONS
• Acute Respiratory Distress
Syndrome and Respiratory
Failure
• Sepsis +/- Septic Shock
• Disseminated Intravascular
Coagulation
• Pulmonary Embolism
• Arrhythmias / Heart Failure
SEPSIS RED FLAGS
▪ New altered mental state
▪ RR ≥25 or new need for ≥40% O2
▪ Heart rate ≥130/min
▪ SBP <90mmHg
▪ No urine in last 12 hours (or <0.5ml/kg/hr)
▪ Lactate >2 (if >4 refer to critical care)
▪ Coagulopathy
Use
COVID-19 Severity Assessment tool
ASK-ASSESS-SCORE-GRADE
https://bit.ly/2yaqhXK

Ref: Wallis et at Afr J Emerg Med. 2020 Apr 2 (doi: 10.1016/j.afjem.2020.03.002)
(Fahrenheit ≤95*, ≥101*)

How is care of COVID-19 patients determined?
Severity of Disease Resources requirement
Mild
Moderate
Severe
Critical
Mechanical Ventilation
Oxygen Therapy
Isolation

RESPIRATORY SUPPORT
Oxygen Maintain Sats 90 - 96% (88-
92% in known COPD with CO2
retention) Target lowered
anticipating shortage of oxygen
supply
Nasal Cannulae 1-5 litres/min
Hudson mask 5-10 litres/min
Non rebreathe mask – 10-15
litres/min and 100%
HFNC—60-70L/min and 100%
Reserve Fixed performance Venturi
masks (40%-60%) for those at risk of
hypercapnia
FLUID MANAGEMENT
• AVOID vigorous fluid resuscitation –
patients rarely shocked on admission (it
may exacerbate ARDS)
• Assess fluid status and encourage oral
rehydration where possible
• Consider gentle IV fluid to cover
insensible losses (high Temp and RR) -
max 2 litres/day
REMEMBER
• Antiviral or other
immunomodulatory medications
should only be used as part of a clinical
trial, NO TREATMENT HAS PROVEN
BENEFIT YET
• Empirical antibiotics for suspected
bacterial pneumonia
• Corticosteroids should NOT generally
be used (unless for co-existent
indication)
• Prone positioning – see below
• Thromboprophylaxis – It is a
hypercoagulable condition
PRONE POSITIONING IN COVID-19 Oxygenation in patients ventilated on Intensive Care improves
significantly with intermittent prone positioning It is less clear whether this intervention improves
symptoms or outcomes in pre-Critical Care patients but anecdotally it does
When to consider discussion with
Critical Care Team?
▪ Severe acute respiratory distress
▪ Persistent hypoxia SaO2 <92% or
(if done) PaO2 <8Kpa despite
maximal oxygen
▪ Progressive hypercapnia
▪ Severe acidosis (pH<7.26) or Septic
shock despite resuscitation or
Lactate >4
When to switch from IV to
oral antibiotics?
▪ Oral route intact (Orals:
use antibiotic according to
local guidelines)
▪ Objective improvement
for 24 hours (e.g. RR
decreasing, SaO2
increasing, etc.
When to discharge home?
▪ Modifiable risk factors have objectively improved for 48-72 hrs
▪ Ability to maintain oral intake and social conditions are acceptable
▪ Discharge after shower and in clean clothes
▪ Advise to seek attention if worsening
▪ Patients should not use public transport
▪ Patients should be advised to self-isolate for 13 days from symptom
onset with atleast 3 days without symptoms before release from
isolation
▪ Patients should be advised about hand and cough / sneezing, etc.
hygiene
1-4: GREEN
MILD / MODERATE
Less likely to need Oxygen
5-7: YELLOW
SEVERE
Less likely to need mechanical
ventilation
Likely needs Oxygen
8+: RED
CRITICAL
Probably needs mechanical
ventilation
Management – Non-Severe / Home
CATEGORY A PATIENTS
▪ Home (unless clinical judgement =
NO)
▪ Analgesia and / or antipyretics as
needed
▪ Oral fluids
▪ Antibiotics: If pneumonia or any
other superadded infection- use
antibiotic according to local guideline
Management – Non-Severe / Hospital
CATEGORY B PATIENTS
▪ Admit unless judgement = discharge is
safe
▪ Oxygen as indicated (target SaO2 90-
96%; 88-92% if risk of type II respiratory
failure)
▪ DVT prophylaxis with LMWH
▪Dexamethasone 6 mg PO/IV for 10
days
▪ Escalation plan to HDU/ICU
▪ Oral/IV fluids to maintain urine output
≥0.5mL/Kg/hour; target = euvolaemia
▪ Antibiotics: If pneumonia or any other
superadded infection- use antibiotic
according to local guideline.
Management – Severe/ Hospital/
Admit
CATEGORY C PATIENTS
▪ Oxygen as indicated (target SaO2
90-96%; 88-92% if risk of type II
respiratory failure)
▪ Consider CPAP/NIV/HFNC
▪Dexamethasone 6 mg PO/IV for 10
days
▪ DVT prophylaxis with LMWH
▪ Escalation plan to HDU/ITU
▪ Oral/IV fluids to maintain urine
output ≥0.5mL/Kg/hour; target =
euvolaemia
▪ Antibiotics: If pneumonia or any
other superadded infection- use
antibiotic according to local
guideline

Effect of prone positioning
https://emcrit.org/ibcc/covid19/
High flow and Titrate FiO2 to
keep O2 saturation more than
90% and also consider awake
proning
CPAP/BiPAP


https://i0.wp.com/emcrit.org/wp-content/uploads/2020/05/ics1.jpg?resize=623%2C891&ssl=1
Awake Proning Process

https://i0.wp.com/emcrit.org/wp-content/uploads/2020/05/ics1.jpg?resize=623%2C891&ssl=1

2.5 Emergency Department Triage guideline for
suspected COVID-19 Patients
Dr Lunik Rollei Sarder
Aim:
1. Effective early clinical diagnosis and initiation of treatment in any designated
COVID-19 unit with standard or minimal or no investigation facilities.
2. Categorise suspected cases and early recognition of the level of care
required.
3. Preventing transmission of disease to the community, other patients and care
providers.
Settings:
1. Isolated room for triage: Assessment and documentation to take place in
opposite corners of the room by different individuals to minimise contamination.
a. Assessment corner: Assessment bed or trolley, nonfabric/synthetic
mattress or cover.
b. Documentation corner: Table, chair, patient notes, investigation forms,
stationery for documentation ideally at least 6 ft away from assessment
trolley.
c. If possible arrange separate entry or exit for the room and if not
possible ensure free corridor for entry/exit to prevent droplet spread.
d. If there is unidirectional airflow in the room, the arrangement should be
such that the flow is maintained from documentation corner to the
assessment corner (source of air may be window/air conditioner).
e. One patient to be allowed to enter the assessment room in any given
time.
f. No more than one accompanying attendant with the patient allowed in
assessment room to prevent the spreading of disease.
2. Required Team members:(three persons)
a. Assessment Doctor- one
b. Nurse or Health care assistant to do observation - one
c. Second doctor for documentation/ treatment prescription/ request
investigations (not in contact of the patient)– one (If the second doctor
is not available, documentation can be done by Nursing staffs /
Paramedics/ Medical assistants using simplified proforma attached).
3. Personal Protective Equipment:
a. Surgical face mask: for all team members (Need to be changed if moist
or contaminated). N95, KN95, FFP2 mask and face shield for AGPs.
b. Disposable polythene/ plastic apron for assessment doctor and nurse
(Need to be changed in between every patient)
c. Disposable gloves for assessing doctor and nurse. Need to wash
hands in between every patient.
d. Care provider must not touch face without washing hands with soap for
at least 20 seconds to prevent fomite transmission.

4. Prevent transmission:
a. Patients and attendants to wear surgical face masks all the time.
b. The bed mattress must be cleaned with an antiseptic (eg: i. 70%
isopropyl alcohol with 0.5% chlorhexidine or ii. appropriate antiseptic
approved by Drug Authority Bangladesh) after assessing every patient
(and change of bedsheet every time where applicable) to prevent
fomite transmission.
c. Patient notes to be handed over to the patient’s attendant (for non-
admitting patients)/ or healthcare worker transferring the patient to the
ward (for admitting patients) in a plastic envelope and wiped frequently
to prevent fomite transmission.
d. Social distance should be maintained where possible without any
exception.
e. Regular hand wash to be ensured.
5. Medical equipment: Need to be wiped with an antiseptic (eg. as above) after
assessing every patient.
a. Blood pressure monitor
b. Thermometer
c. Pulse oximeter
d. Stethoscope
References:
• Specialty guides for patient management during the coronavirus pandemic Clinical guide for
the management of emergency department patients during the coronavirus pandemic 17
March 2020 Version 1
• World Health Organization. Infection prevention and control during health care when novel
coronavirus (nCoV) infection is suspected. Accessed on March 20
• COVID-19: investigation and initial clinical management of possible cases, PHE 18th
March
2020
• King’s Critical Care – Evidence Summery Clinical management of COVID – 19
• Loss of sense of smell as marker of COVID-19 infection - ENTU

Emergency Department Triage guideline for suspected COVID-19 Patients for
Universal Healthcare Settings in Bangladesh:
Triage Flowchart
Symptoms:
Persistent cough - Acute onset (with or without sputum) and/or
Fever ≥37.8°C and/or
Dyspnoea and/or Sore throat/ Myalgia/
Rhinorrhoea/Headache/Anosmia/
Suspect COVID 19
Unlikely COVID19
Clinical Examination
1. Visible respiratory distress
2. Resp Rate: >21
3. SpO2: on air <92%/ 88% (COPD)
4. Patient looks unwell
5. Clinically no signs of Heart
failure/ renal failure
(In absence of other possible causes)
Likely Moderate to Severe
Disease (Need admission)
1. No Respiratory signs with
normal observation
2. Normal examination findings
3. Eating and drinking
4. No uncontrolled underlying
significant health condition (like
IHD/ DM/ HTN)
5. Self caring or available support
and understand own
Likely Mild Disease
No investigations required
(Discharge with advice)
Consider
alternative Diagnosis
YES
YES
Clinically mild to
moderate catagory
Intermediate Category (Need
Admission) for ward-based
short observation and
investigations to assess clinical
need (risk of developing
moderate/ severe disease )
No
YES
YES
Oxygen Challenge
15L NRM and titrate Sats
90-96% (88-92 % in COPD) Supportive care (if required)
1. Antipyretics
2. IVF if clinically very dehydrated/
hypotensive (neutral fluid balance)
3. Consider antibiotics if suspected
Bacterial Sepsis
4. Thromboprophylaxis (mandatory)
5. Proning
investigations
Immediate/ Essential:CXR CBC CRP U&E LFT
Clotting COVID-19 Swab
If available:D-dimer Ferritin CK LDH ABG
CT Chest (where dedicated CT unit present) Others:
Blood C/S, ECG, Troponin
Unable to achieve target saturation
with Oxygen or ongoing fatigue with
severe respiratory distress
Severe Disease
Critical Care
management for NIV
or Invasive Ventilation
(Refer to higher
centers if facilities not
available locally)
Moderate Disease
Ward base care with
oxygen support and
regular monitoring.
Treat accordingly if
develop severe disease
YES NO

Emergency Department Triage guideline for suspected COVID-19 Patients for Universal
Healthcare Settings in Bangladesh: Triage Proforma
Name:
DOB/ Age:
Next of Kin:
Hospital Number:
Phone number:
Address:
Presenting Complaints (Please tick as appropriate with duration)
 Fever …….. days
 Cough …….. days
 Sputum …….. days
 SOB …….. days
 Abdo pain ……days
 Diarrhoea …….. days
 URT Symptoms ……days
 Myalgia/ Rhinorrhoea/Headache…….days
 Anosmia/hyposmia …….days
 Others:
Observations
RR SpO2 Temp BP HR GCS
Examination
Respiratory Distress: Y / N, Cyanosis: Y/ N , Pale/ Clammy: Y/ N
A: B:
C: CRT: Sec
JVP: Elevated/ Not
Oedema: Present (Up to ) / Absent
Heart sounds: S1 + S2 +
D: GCS: ………/ 15 (E: / 4, M: / 6, V:
Neurology:
E:
Diagnosis /Management plan
Primary Dx: COVID19  Moderate or severe  Intermediate category  Mild disease 
Oxygen 
Supportive Rx 
Investigation 
Ward/ ITU admission 
Supportive Rx 
Investigation 
Ward Admission 
Advice given 
No investigation 
Discharge home 
Secondary Diagnosis

2.6 Management of C19 at Upazilla and District level
Dr Zahed Ikram, Prof S A Fattah, Dr Shakil Farid, Dr. Samiul Huda
Resources:
Level Upazilla Hospitals District Hospitals
Total Number 493 64
Feeding centres Union subcentres
Family Welfare Centres
Community Clinics
Upazila Hospitals
Bed capacity 31-50 Mostly 100, some 250
Isolation 5 Needs to be Divided into COVID/Non
COVID zones (?50/50 proportion)
Doctors
Consultants
Anaesthetist
Medical Officers
13 18
10 (50% posts are vacant)) 20
1 (usually not specialists) 2
3 10 (indoor)
4 (outdoor)
Nurses 20-35 70
Lab Techs 4 2
Ambulances 1-2 2
Field Staff
Health Inspector
Assistant Health Inspector
Health Assistant
80 (variable, depends on the catchment area NA
5 NA
15 NA
60 NA
Operating Theatre 1 (roughly 50% are not used) 2 + postop ward
Oxygen supply Cylinders Cylinders mostly, some has central
Oxygen
Pulse oximeters Available Available
ICU Not available Some has ICU

Management Plan:
Upazilla Hospitals District Hospitals
1. Passive case detection: Patients attending health
centres by themselves physically or over telephone.
Each centre will keep one phone number open to
public for corona related advice.
2. Active case detection: Field staff to triage at
community level, screening families door to door for
C19 symptoms. For symptomatic patients, staff can
collect samples for COVID test, provide advice for
home quarantine. Field staff to follow up regularly to
monitor quarantine and for deterioration.
3. In case of deterioration, refer to UZ or District
Hospital. Ambulance to be provided for transport.
4. Admission required for patients needing oxygen
supplementation plus unwell patients.
5. UZ hospital to increase isolation beds to 15 for C19
cases requiring supplemental oxygen or otherwise
unwell.
6. Dexamethasone 6 mg po/IV if on oxygen
7. Thromboprophylaxis for all hospitalised C19
patients for 28 days unless contraindicated.
8. Awake proning for all patients requiring
supplemental oxygen.
1. Triage in temporarily built tent area outside
Emergency Room.
2. Introduce zoning system, with C19/PUI zones
(red/yellow) and non C19 (green) zones.
3. Admission required for C19 patients with
requirements which cannot be met at UZ level.
4. For hospitals with central oxygen, convert theatre
to ICU/HDU beds.
5. If central oxygen present, acquire NRB mask,
HFNC and CPAP machines in HDU area.
6. Dexamethasone 6 mg po/IV if on oxygen
7. Thromboprophylaxis for all hospital admitted
patients.
8. Awake proning for all C19 patients requiring
supplemental oxygen.
Key points:
*Any patient who deteriorates and needs a higher level of care to be transferred
urgently to Tertiary Hospital for HFNC/NIV/Invasive Ventilation.
*Transport between hospitals to be provided.
*All hospitals to have defined catchment area for taking C19 cases.
*District hospitals will be linked to specific tertiary hospitals for referral. Any
specialized hospitals at district level or bigger city will be included in this system.
*Online database of available C19 beds.
*Communication between hospitals regarding bed availability prior to transfer.

Escalation Plan
1. Passive case detection
2. Active case detection
3. In case of deterioration, refer
to UZ or District Hospital.
4. Admission required for
patients needing oxygen
supplementation plus unwell
patients.
5. Low dose Dexamethasone (6
mg oral/IV for 10 days) in
patients needing oxygen.
6. UZ hospital to increase
isolation beds
7. Thromboprophylaxis
8. Awake proning
Upazilla Level Escalation
District Level
1. Triage in temporarily built tent area
outside Emergency Room.
2. Introduce zoning system, with C19/PUI
zones (red/yellow) and non C19 (green)
zones.
3. Admission required for C19 patients
with requirements which cannot be
met at UZ level.
4. For hospitals with central oxygen,
convert theatre to ICU/HDU beds.
5. If central oxygen present, NRB, HFNC
and CPAP machines in HDU area.
6. Thromboprophylaxis
7. Continue low dose Dexamethasone
(6mg oral/IV for 10 days) in patients
needing oxygen.
8. Awake proning
TERTIARY
HOSPITALS
1. HFNC/CPAP/BIPAP
2. VENTILATION
Escalation

Suggested Triage Plan for Hospitals

Suggested Zoning Plan for 50 bed Upazilla Hospital
COVID-19 Suspects
General Patients
OPD- General
Stairs to 1st Floor
Stairs to 1st Floor
Lab
Mo
Station
Emer-
gency
Flu Clinic
Gate
Kitchen
DOTS
Corner
Triage
Station
SACMO
Room
Ground Floor
Collapsible Gate
Legend
UP
UP
Office of
UHFPO
Initial Triage by
Primary Healthcare Workers
First Floor
Collapsible Gate
Legend
Store
Green
Male
Green
Female
Labour
Room
Store
Stairs
Stairs
Red
Male
3 Beds
Amber
Male
12 Beds
Nurse
Station
Amber +Red
Amber
Female
12 Beds
Red
Female
2Beds
DOWN
DOWN
Nurse
Station
Green
OT Complex
T
TT
T
Sumaiya Tasnim Prottasha
L-5 T-2, Dept of Architecture, BUET

2.7 COVID-19 isolation and discharge pathways
Dr Shakil Farid, Dr Sarkar Haider, Dr Zahed Ikram
Criteria for discharge of patients to own home:
1. Patient’s clinical status is appropriate for discharge.
2. Patient should be afebrile (temp <37.8*
C) for 48-72 hours and should have
improved or recovering respiratory symptoms (except cough, which can
persist for longer period).
WHO discharge pathway (updated version June 16th
2020)
Discontinue transmission-based precautions (including isolation) and release from
the COVID-19 care pathway as follows:
It is important to note that WHO has recommended the isolation advice based on
clinical criteria rather the test based criteria because of the lack of adequate testing
facilities in many countries and also because of the fact that RT-PCR test can be
positive in patients many weeks following resolution of symptoms.
The isolations advices are as follows:
1. For symptomatic cases: The clinical criteria require the patient to be symptom
free for at least 3 days (no fever without antipyretics and resolution of
respiratory symptoms, however, post viral cough may persist) prior to release
from isolation with a minimum time of 13 days from the onset of symptoms.
2. In patients with severe disease who are symptomatic for prolonged periods a
laboratory based approach might also aid decision making on the need for
prolonged isolation.
3. For asymptomatic patients, isolation should be for at least 10 days from the
day of a positive test.
Ref:
Clinical management of Covid-19. WHO interim Guidance. June 16, 2020.

2.8 Role of antimicrobials in Covid-19
Dr Zahed Ikram, Dr Tasbirul Islam
Important terms –
1. Coinfection: An infection occurring concurrently with the initial infection.
2. Superinfection/secondary infection: An infection following a previous infection
especially when caused by microorganisms that are resistant or have become
resistant to the antibiotics used earlier.
What does the evidence say?
Evidence is scarce due to reluctance to collect specimens, need to minimise
exposure to respiratory secretions, and for preservation of PPE.
1. Coinfections with other respiratory viruses is very common, but not more so
than in non-Covid-19 respiratory viral illnesses.
2. There is little evidence of bacterial coinfection in the early stages.
3. Superinfections/secondary infections are reportedly common in hospitalized,
severely ill patients, encompassing between 10-30% of cases, with greater
frequency in the ICU setting.
4. Patients with severe illness are much more likely to have bacterial/fungal
secondary infections than viral.
5. ICU patients with prolonged illness/intubation have more frequent detection of
multidrug-resistant Gram negative pathogens, likely reflecting hospital-
acquired infection.
Until better evidence is available, the following is some practical guidance, based on
available evidence:
1. Antibiotics should be reserved for those with the most severe presentations,
such as high oxygen demands and rapidly progressing respiratory failure.
2. So far as is practically possible, antibiotic prescription should be based on
blood culture, respiratory secretion culture, CT scan results.
3. Need to continue antibiotics should be regularly evaluated, based on results
of investigations, and a rapid oral switch should be considered to lessen
contact time for nurses.
4. If antibiotics are considered, a β-lactam providing cover for S. pneumonia ±
methicillin-susceptible S. aureus should be the first option (e.g.
amoxicillin+clavulinic acid or third-generation cephalosporins). Once-a-day
antibiotics should be chosen when possible. Macrolides and Quinolones
should be avoided because of their cardiac side effects (especially if
hydroxychloquine/chloroquine/lopinavir-ritonavir are also being used).
5. In ICU patient where ventilator-associated pneumonia (VAP) or other
healthcare-associated infections are being considered, follow local and

patient-level resistance data, and if possible get specimens from lower
respiratory tract.
6. Antibiotics should not be given prophylactically to prevent bacterial
pneumonia.
7. If secondary respiratory worsening occurs, consider hyper-inflammatory
phase of Covid-19 infection, cardiogenic failure, pulmonary embolism, fluid
overload, before considering antibiotics.
8. Do not forget to consider infections at other sites – urinary tract, skin, soft
tissue, intra-abdominal etc.
References:
1. Superinfections and Coinfections in Covid-19 – Separating the signal from the
noise. Kwon, Li, Dalai.
www.medpagetoday.com/infectiousdisease/covid19/86192. April 28, 2020.
2. Covid-19: don’t neglect antimicrobial stewardship principles! Huttner, Catho,
Schouten. Clinical Microbiology and Infection. April 24, 2020.
3. Bacterial and fungal co-infection in individuals with coronavirus: A rapid
review to support COVID-19 antimicrobial prescribing. Rawson, Moore,
Holmes. Clinical Infectious Diseases. May 2, 2020.

Empiric Use of Antifungals in ICU:
• Still no good clinical data for empiric antifungal treatment in non-neutropenic
patient. It ranges from 1 to 10 per 1000 ICU admissions.
• Invasive fungal infection in critically ill patients are associated with
considerable morbidity and mortality (30-40%).
• Candida and Aspergillus species are the most common causes of fungal
infections in ICU patients.
• Fungal infections in COVID-19 patients have been inadequately investigated
and reported so far.
• 8% of COVID-19 patient (62/806) patients had bacterial/fungal co-infection
during hospital admission. On secondary analysis, 72% of patients received
antimicrobial therapy. No antimicrobial stewardship interventions were
described.
• The gold standard for the diagnosis of invasive candida remains blood culture,
which may miss more than 50% of cases in bloodstream infections and up to
80% in deep-seated candidiasis.
• Galactomannan (GM) and 1,3-β-d-glucan (BDG) are useful adjunct tools for
early detection.
• Risk factors predisposing fungal infection:
• Initial empiric antifungal therapy: EMPIRICUS trial
 1st line: Echinocandin (Anidulafungin or Caspofungin)
 2nd line: Fluconazole, liposomal amphotericin B

COLISTIN:
• Old but toxic drug. Introduced in 1959.
• Now being used with increasing frequency due to MDR gram negative
organism (Pseudomonas, Acinetobacter, E Coli, Klebsiella, Enterobacter,
Citrobacter).
• Bactericidal drugs that bind to lipopolysaccharides (LPS) and phospholipids in
the outer cell membrane of gram-negative bacteria.
• Resistance is uncommon.
• Available in inhalation and intravenous form
• Concerns about neurotoxicity and nephrotoxicity
• Should be reserved for MDR aerobic Gram negative organism.
Criteria to start pre-emptive antifungal therapy
Patient in ICU > 4
days.
Persistent Fever
Abx in the last 7 days
+/-
CVC from 7 days
2 of the following:
• Total parenteral nutrition (days 1-3)
• Any dialysis (days 1-3)
• Major surgery (days -7-0)
• Pancreatitis (days -7-0)
• Any use of steroids (Days -7-3)
• Immunosuppressive agents (days -7-0)
Candida colonization or
(1-3)- β-D- Glucan
Start Antifungal

References:
• Diagnosis of invasive candidiasis in the ICU. Ann Intensive Care 2011;1:37.
• Clinical Infectious Diseases, ciaa530, https://doi.org/10.1093/cid/ciaa530
• Clancy and Nguyen. J Clinical Microbiology 2018 April 25; 56(5):
• Jean-Francois Timsit. JAMA. 2016;316(15):1555-1564.

2.9 Evidence for specific pharmacological treatment for
COVID-19
Dr Sarah Choudhury, Dr Zahed Ikram
Effective therapy for this virus is finally emerging, with preliminary results of major
trials being released early. Below we go through some of the common repurposed
drugs that are being used in various trials –
Pharmacological
agent
Key Trials Verdict
Corticosteroids RECOVERY trial - RCT to test a
range of potential treatments for
Covid-19. Over 11,500 patients
enrolled in the UK. Primary
endpoint – 28 day mortality. The
trial included a steroid arm of
dexamethasone 6 mg po or IV for
10 days.
Among patients who received usual
care, 28 day mortality was 41% in
ventilated patients, 25% in those
requiring oxygen and 13% in those
not requiring respiratory
intervention. Dexamethasone
reduced deaths by 1/3rd
in
ventilated patients (RR 0.65,
p=0.0003), and by 1/5th in patients
requiring oxygen only (RR 0.80,
p=0.0021). There was no benefit
among the patients who did not
require respiratory support (RR
1.22, p=0.14).
Dexamethasone prevented 1 in 8
deaths in ventilated patients and 1
in 25 deaths in those requiring
oxygen. It should not be given to
those not requiring respiratory
support as there was a non-
significant increase in mortality in
that group compared to control.
Full report awaited.
In C-19 patients
requiring oxygen
supplementation, or if
intubated,
Dexamethasone 6 mg
po/IV for 10 days is
recommended.
Effect of higher doses
unknown.
Steroids should not be
used in patients not
requiring oxygen
supplementation.
Strong
recommendation
Remdesivir Remdesivir is a non-specific
inhibitor of viral RNA-dependent
Can be used in
patients requiring
oxygen

RNA polymerase.
On 1 May 2020, the U.S. FDA
granted Emergency Use
Authorisation (EUA) for remdesivir
to be used for severe Covid-19
(requiring supplemental oxygen or
breathing support).
SIMPLE trial (double blinded RCT)
- no difference between the 5 and
10 day course in primary endpoint
of time to recovery.
Remdesivir for the Treatment of
Covid-19 – Preliminary Report
The ACTT-1 Clinical trial.
Double-blind RCT of intravenous
remdesivir in adults Covid-19
confirmed patients hospitalized with
evidence of lower respiratory tract
involvement.
The primary outcome - time to
recovery.
Trial was stopped early after an
interim analysis.
Those who had remdesivir had a
median recovery time of 11 days,
as compared with 15 days in the
placebo group.
There was no significant mortality
benefit, though mortality was lower
in the Remdesivir group.
Remdesivir was started 6-12 days
after onset of symptoms.
Patients who benefit were those
who were hospitalized and
requiring supplemental oxygen.
Hospitalized patients not requiring
oxygen did not benefit, nor did
those requiring mechanical
ventilation.
At the time of recruitment, there
were 125 patients in the
Remdesivir arm on invasive
mechanical ventilation, while there
were 147 on invasive mechanical
ventilation in the placebo arm.
Further analysis is awaited.
supplementation to
shorten time to
recovery. No evidence
of benefit in mild or
critical cases.
Dose 200 mg IV day 1.
100 mg IV day 2-5.
Soft
recommendation

Hydroxychloroquine
(HCQ) and
Chloroquine, with or
without
Azithromycin
On 24th
April, 2020, US FDA
cautioned against the use of HCQ
or Chloroquine for Covid-19 outside
of the hospital setting or in a clinical
trial due to the risk of cardiac
arrhythmia. Reports have been
received of serious heart-related
adverse events and death in
patients with COVID-19 receiving
HCQ/Chloroquine, either alone or
combined with azithromycin or
other QT prolonging
medicines. Adverse events were
reported from the hospital and
outpatient settings for treating or
preventing COVID-19, and included
QT interval prolongation,
ventricular tachycardia and
ventricular fibrillation, and in some
cases death.
In a large observational study, of
1376 consecutive patients in New
York, hospitalized with Covid-19
patients, HCQ was not associated
with any increased or decreased
risk of intubation or death.
RECOVERY trial (RCT) announced
that they were stopping the
hydroxychloroquine arm of the trial,
as the Independent Data
Monitoring Committee had
analysed the data and concluded
HCQ had no beneficial effect on
hospitalised patients with Covid-19.
Primary endpoint – mortality,
secondary endpoint – time to
recovery.
RCT of post exposure prophylaxis
with hydroxychloroquine showed
no benefit. Exposure was defined
as household or occupational
exposure to Covid-19 at a distance
of less than 6 feet for more than 10
minutes.
HCQ and Chloroquine
are not effective in
either treatment or
prevention of Covid-
19. They cause
cardiac arrhythmias.
The risk of cardiac
arrhythmias is
increased further when
used in combination
with Azithromycin.
Not recommended
for treatment or
prophylaxis
Doxycycline No studies currently available.
Weak theoretical basis of possible
benefit.
Not recommended

Lopinavir-Ritonavir Open labelled RCT, in 199 patients
comparing Lopinavir-Ritonavir with
standard care. This showed no
difference in primary endpoints of
time to improvement or discharge
from hospital. The combination
prolongs QT interval.
Part of RECOVERY trial. Results
awaited.
Awaiting evidence
Ribavarin Inconclusive data and produces
significant dose dependent
haematologic toxicity.
Not recommended –
no ongoing phase 3
trials
Ostelmavir Oseltamivir is a neuraminidase
inhibitor used for prophylaxis and
treatment of influenza. No clear
mechanism of action against
COVID-19.
Has been used in combinations of
antiviral therapy in Wuhan and
continues to be explored as a
therapeutic option as part of
combination regimens. No trial or
case report as monotherapy.
Not recommended –
no ongoing trials
Favipiravir (Avigan) This is being manufactured and
used in Bangladesh.
It is currently used to treat
influenza. Previous trial in China
was inconclusive due to poor trial
design.
RCT ongoing in India.
Awaiting evidence
Umifenovir A non-randomised study in China
on 67 patients showed lower
mortality and higher discharge
rates. A more recent retrospective
study in non-ICU patients showed
no benefit.
Ongoing RCT.
Awaiting evidence
Type 1 Interferon
alpha and beta
These have some antiviral effect.
No RCTs available.
Awaiting evidence
Ivermectin Ivermectin is an antiparasitic drug
which has weak antiviral effect
against single-strain RNA viruses
like Dengue and Yellow fever.
Researchers from Australia
reported that Ivermectin inhibits the
replication of SARS-CoV-2 in vitro.
Not recommended –
no ongoing RCTs

They used concentrations that are
not achievable in the human body,
but this opened the door to both
unlicensed use and clinical trials.
It is in widespread use in Latin
America as a therapeutic option for
C19. This is largely based on a pre-
print analysis posted by the
Surgical Outcomes Corporation, of
automated data obtained from a
variety of sources. This data has
been subsequently been shown to
be largely fake and the analysis
has been shown to have serious
methodical flaws.
No RCTs available. No peer
reviewed evidence of benefit.
Anti-cytokine or
Immunomodulatory
agents
The underlying pathophysiology of
significant organ damage in the
lungs and other organs is caused
by an amplified immune response
and cytokine release, or Cytokine
release syndrome. Tocilizumab, a
monoclonal antibody IL-6 receptor
antagonist, has approval from US
FDA to treat RA and cytokine
release syndrome following
chimeric antigen receptor T-cell
therapy. Tocilizumab has been
used in small series of severe
COVID-19 cases with early reports
of success.
*Caution - patients receiving
tocilizumab are often at an
increased risk of serious infections
(bacterial, viral, invasive fungal
infections, and tuberculosis) and
hepatitis B reactivation.
Sarilumab (Kevzara) is also in a
trial in critically ill Covid19 patients.
Awaiting evidence.
Weak
recommendation for
use in CRS while
evidence is awaited.
Convalescent
plasma
There are national programs in
place in the USA and the UK to
collect Convalescent Plasma from
people who have recovered from
C19. These efforts are part of
clinical trials, as the intervention is
as yet of unproven benefit – the
only evidence available is from very
small case series. Many centres
are no longer waiting for the
The questions that
need to be asked of
clinical trials are –
Does it work? If it
works, which stage of
the disease does it
work in?
Does it confer passive
immunity?

evidence and have made it their
therapeutic intervention of choice.
What titre of antibody
is required for it to be
effective, if it is?
Is it safe (possible
dangers are
transfusion related
lung injury, disease
transmission, antibody
dependent
enhancement)?
Evidence awaited.
Should not be used
without measuring
antibody titre.
Intravenous
Immunoglobulin
Intravenous immunoglobulin (IVIg)
has been used as an adjuvant to
treat a variety of pathogens either
as a pooled product or in a
concentrated more pathogen
focused (hyperimmune) form. As
the community from which a given
batch of IVIg is derived from
includes increasing numbers of
individuals who have recovered
from SARS-CoV-2, the possibility
of protective antibodies being
present in the pooled product is
increased. Utility of IVIg in SARS-
CoV-2 is unknown at this time.
Evidence awaited
Famotidine The only trial available is a non-
peer reviewed retrospective
analysis which should not influence
clinical decision making.
Evidence awaited
LY-Cov555 Synthetic antibody against SARS-
Cov-2.
Phase I trial ongoing.
Evidence awaited
Key points:
1. As Covid-19 is a new disease and most patients make a full recovery, use of
experimental drugs outside of trials is not recommended. The likelihood is that
unless administered within strict trial protocols, these drugs will harm some patients.
These trials are necessary to establish efficacy, safety, dose, categories of patients
who will benefit etc. Anecdotal evidence is not useful as most of these patients
recover with supportive treatment or with no intervention. Laboratory evidence also is
insufficient.
2. Dexamethasone decreases mortality in patients requiring oxygen or on ventilator
support, but should not be used in those not requiring respiratory support.

3. We are currently recommending Remdesivir only for hospitalized patients
requiring supplemental oxygen, and not for those not needing oxygen or needing any
form of ventilation. It should be started 6-12 days after onset of illness if used.
However, mortality benefit is as yet unestablished.
4. There is no evidence that the anti-malarial drugs Hydroxychloroquine and
Chloroquine are effective either alone or in combination with Azithromycin in
treatment or for prophylaxis of Covid-19. The combined use of these drugs increases
toxicity – they cause cardiac arrhythmias.
5. Favipiravir is an influenza drug of unknown efficacy in Covid-19.
6. There is also no evidence that Doxycycline is effective.
7. There are no human trials available with Ivermectin. Laboratory studies suggest
that the doses required for it to have any possible beneficial effect in humans is 10-
30 times the recommended dose in humans.
8. Convalescent plasma trials are ongoing, but currently we do not know which
patients may benefit from this, what titre of antibody is needed, and also regarding
safety.
9. There is insufficient evidence that Lopinavir/ritonavir is effective.
10. There is insufficient evidence regarding the efficacy and safety of IL-6 inhibitors
such as Toclizumab for them to be used outside of clinical trials, with the possible
exception of the ICU setting (rapidly deteriorating patient or in CRS) at present.
SO WHAT DOES WORK?
Triage
This helps us to identify those patients who can be managed at home and those who
need assessment in or admission to hospital.
Supportive care
1. Careful fluid balance, to avoid and treat acute kidney injury, and to avoid fluid
accumulation in the lungs
2. Titration of blood pressure medication to avoid hypotension
3. Nutritional support
4. VTE prophylaxis
5. Management of comorbidities
6. Adjusting immunosuppressive medication according to recommendations
given in this handbook
7. Safe glycemic control (recommendations given in this handbook)
8. Early identification and treatment of secondary bacterial infection/sepsis
9. Identification of Covid-19 mimickers – bacterial sepsis, pneumonia, heart
failure, PE
10.Early identification of hypoxia
11.Early identification of secondary PE
12.Early identification of type-2 MI
13.Early identification of deteriorating patient requiring ICU care (use NEWS2
score – mdcalc.com)
14.Early identification of dying patient requiring palliation
15.Discussions regarding ceiling of care

Oxygen
It is strongly recommended that rather than focusing resources on drugs of dubious
value, oxygen supply should be improved. Recommended oxygen saturation range
for Covid-19 patients with lung involvement is 92-96%. However, a lower target of
90-94% is adequate if oxygen supply/flow so demands.
More use of CPAP
This applies a single, fixed pressure throughout inspiration and expiration via a tight
fitting nasal or whole face mask to the spontaneously breathing, conscious patient
without the need for intubation or sedation. This can be used as a trial to avoid
intubation or to facilitate extubation, or can be set as the ceiling of care if the clinical
decision is that the patient will not survive mechanical ventilation. This can be done
in a sideroom/cabin – no need for ICU.
High Flow Nasal Cannula Oxygen (HFNCO)
This is an oxygen supply system capable of delivering up to 100% humidified and
heated oxygen at a flow rate up to 60 L/min via nasal cannulae.
Awake Proning
The merits of this have been discussed elsewhere in this handbook. Non-ICU
patients with lung involvement (alveolar pneumonitis) from Covid-19 may benefit
from a proning schedule.
Thromboprophylaxis
All hospital admitted Covid-19 patients should have this, especially given the high
incidence of thromboembolic complications in these patients.
Corticosteroids
Steroids are effective in patients requiring oxygen or on ventilator support and they
reduce mortality. Regimen is given above.
Toclizumab
This may be used in rapidly deteriorating ICU patient and in CRS, provided there is a
degree of certainty that there is no bacterial or fungal infection. Protocol is given in
ICU chapter.
Convalescent Plasma
It remains unclear which, if any, category of patient will benefit from this, but trials
are in full swing, and it is being widely used. Protocol is given in ICU chapter.
Remdesivir

We are currently recommending this only for hospitalized patients requiring
supplemental oxygen, and not for those not needing oxygen or needing any form of
ventilation. If used, we recommend 200 mg loading dose on day 1, followed by 100
mg daily for a further 4 days. Mortality benefit is not proven.
Prophylaxis for healthcare workers
There is currently no evidence that any drugs are effective as prophylaxis for
healthcare workers. We recommend a strategy of appropriate triage, zoning, PPE,
hand-washing, testing, identification of those at increased risk.
References:
• Chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated
pneumonia in clinical studies. GaoJ,TianZ,YangX.Breakthrough: Biosci Trends. 2020;
14(1):72-73.
• Hydroxychloroquine and azithromycin as a treatmentofCOVID-19: results of an open-label
non-randomized clinical trial. Gautret, Lagier, Parola. Int J Antimicrob Agents. Published
online March 20, 2020.
• A pilot study of hydroxychloroquine in treatment of patients with common coronavirus
disease-19 (COVID-19). ChenJ,LiuD,LiuL,etal. J Zhejiang Univ (Med Sci). Published online
March 6, 2020.
• Observational study of Hydroxychloroquine in hospitalized patients with Covid-19. Geleris,
Sun, Zucker. NEJM;May 7, 2020.
• www.fda.gov. Hydroxychloroquine or Chloroquine for Covid-19: Drug safety – FDA
• A randomised trial of hydroxychloroquine as postexposure prophylaxis for Covid-19.
Boulware, Pullen, Pastick. NEJM, June 3 2020.
• A trial of lopinavir-ritonavir in adults hospitalized with severe COVID-19. Cao, Wang, Wen.
NEJM. May 7, 2020.
• StockmanLJ,BellamyR,GarnerP.SARS: systematic review of treatment effects. PLoS Med.
2006;3(9):e343.
• WangZ,YangB,LiQ,WenL,ZhangR.Clinical Features of 69 cases with coronavirus disease
2019 in Wuhan, China. Clin Infect Dis. Published online March 16, 2020.
• KalilAC.TreatingCOVID-19—off-label drug use, compassionate use, and randomized clinical
trials during pandemics. JAMA. Published March 24, 2020.
• Umifenovir treatment is not associated with improved outcomes in patients with coronavirus
disease 2019: a retrospective study. Lian, Zie, Lin. Clinical Microbiology and infection. April
25, 2020.
• Remdesivir for the Treatment of Covid-19 – Preliminary Report. The ACTT-1 Study Group.
NEJM, May 22, 2020.
• Wang, Zhang, Du G; remdesivir in adults with severe COVID-19: A randomised,
double-blinded, placebo controlled, multicentre trial. Lancet April 29 2020
• https://www.statnews.com/2020/05/11/inside-the-nihs-controversial-decision-to-stop-its-big-
remdesivir-study/

• SARS: systematic review of treatment effects. Stockman, Bellamy, Garner PLoS Med.
2006;3(9):e343.
• HLH Across Specialty Collaboration, UK. COVID-19: consider cytokine storm syndromes and
immunosuppression. Mehta, McAuley, Manson JJ;Lancet. 2020;395(10229):1033-1034.
• Convalescent plasma transfusion for the treatment of Covid-19:systemic review. Rajendran,
Krisnasamy. Journal of Medical Virology. May 1, 2020.
• Effect of Convalescent Plasma Therapy on Time to Clinical Improvement in Patients with
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June 2020

3.0 Thromboprophylaxis and management of
coagulopathy in COVID-19
Dr Mehedi Hasan
1. Introduction:
COVID-19 is a systemic infection caused by a novel coronavirus (SARS-CoV-2),
with a significant impact on the hematopoietic system and haemostasis.
Current evidence suggests that patients affected by this novel coronavirus are
more prone to venous thromboembolism (VTE), mainly due to hypoxia, systemic
inflammatory response and prolonged immobilization. Intensive care procedures,
such as mechanical ventilation or central venous cannulation, increase VTE risk
further.
Several coagulation abnormalities have been described so far in these patients,
including elevated D-dimer, prolonged prothrombin time (PT), activated partial
thromboplastin time (APTT) and increase in fibrin degradation products (FDP).
Furthermore, some patients may develop life-threatening complications, such as
disseminated intravascular coagulation (DIC), which necessitates continuous
vigilance and prompt intervention.
Higher D-Dimer levels in COVID-19 patients are associated with worse
prognosis, higher risk of Adult Respiratory Distress Syndrome (ARDS) and
increased chance of admission to intensive care.
2. VTE Prophylaxis:
All patients admitted to hospital with confirmed or suspected COVID-19 should at
least have the following tests:
• Full blood count (FBC)
• Urea & electrolytes
• LFTs
• Coagulation screening
• D-dimer
All patients should be monitored closely for bleeding complications, as well as
heparin-induced thrombocytopenia.
3. All patients should receive mechanical and chemical (unless contraindicated)
prophylaxis for VTE

Fig: Thromboprophylaxis strategy in Moderate to severe COVID
Moderate to Severe COVID
(D-Dimer<1000, no suspicion of PE/DVT)
CrCl>30ml/min
BMI<40
Enoxaparin 40 mg od
BMI>40
Enoxaparin 40 mg bd
CrCl<30ml/min
Enoxaparin 20 mg od
Moderate to Severe
COVID
Confirmed/ High
suspicion of VTE
(PE/DVT)
CrCl>30 ml/min
Enoxaparin 1mg/kg BD
or Apixaban 10 mg BD for
7 days then 5 mg BD for
3-6 months
or Rivaroxaban 15mg/bd
for 3 weeks then 20 mg
od for 3-6 months
eGFR 15-30 ml/min
Enoxaparin 75% of
full dose
eGFR <15 ml/min
Enoxaparin 50%
of full dose
High risk i.e.
High D Dimer >1000
Increasing O2 requirements
eGFR>30 ml/min
Enoxaparin 40 mg bd
eGFR <30 ml/min
Enoxaparin 20 mg bd
When appropriate switch to oral
warfarin for 3-6 months or switch
to DOAC when eGFR>30 ml/min
Consider extended
thromboprophylaxis for up to 4
weeks from discharge with
Enoxaparin/Apixaban 2.5 mg bd
/Rivaroxaban 10 mg od
Baseline and daily: CBC, PT/APTT,
D-dimer, CRP
Oral anticoagulant should be
switched to LMWH or UFH on
admission
Inclusion: All admitted patients with
moderate to severe COVID-19
Exclusion: High risk of bleeding as
judged by treating physician, older
age, advanced liver or renal disease,
previous h/o bleeding
Moderate to Severe
COVID
Confirmed/ High
suspicion of VTE
(PE/DVT)
CrCl>30 ml/min
Enoxaparin 1mg/kg BD
On Discharge: Apixaban 5
mg BD for 3-6 months
or Rivaroxaban 20 mg od
for 3-6 months
CrCl 15-30 ml/min
Enoxaparin 75% of
full dose
CrCl <15 ml/min
Enoxaparin 50%
of full dose
High risk i.e.
High D Dimer >1000
Increasing O2 requirements
CrCl>30 ml/min
Enoxaparin 40 mg bd
CrCl <30 ml/min
Enoxaparin 20 mg bd

Coagulopathy management:
A. Abnormal coagulation results do not require correction in patients
who are not bleeding unless an interventional procedure is planned.
B. In patients with major bleeding stop any anticoagulation, give
empirical Fresh frozen plasma (FFP) and red cells followed by blood
products determined by repeat coagulation screens, using PT/INR
>1.5 or APTT > 1.5 as an indication to give FFP 15-25mg/Kg. For
fibrinogen <1g/l give cryoprecipitate or fibrinogen concentrate. If
platelets <30x 109
/L give a pool of platelets.
C. Management of disseminated intravascular coagulation (DIC) in
COVID-19
DIC can occur in patients in intensive care which may lead to multi-organ
failure.
It is uncertain whether COVID-19 has unique characteristics to cause DIC.
It seems more plausible that DIC develops in patients with COVID-19 after
they become hypoxic, and/or have secondary bacterial infection.
To aid diagnosis of DIC, it is recommended to use the International
Society on Thrombosis and Haemostasis (ISTH) DIC score (Table 4).

Table: Society on Thrombosis and Haemostasis (ISTH) DIC score.
- Score
Platelet Count
>100 x 109
/L 0
50-100 x 109
/L 1
<50 x 109
/L 2
D-dimer
No increase 0
Moderate increase (1 – 10 times
upper limit of normal)
2
Strong increase (> 10 times
upper limit of normal)
3
Fibrinogen
> 1.0 g/L 0
≤ 1.0 g/L 1
Prothrombin time prolongation
< 3 s 0
3 – 6 s 1
> 6 s 2
Overt Disseminated
Intravascular Coagulation
≥ 5
o A score < 5 means DIC is unlikely and the score should be recalculated
every 1-2 days as necessary. The best management of DIC is to identify
and treat the underlying condition.
o Recovery from DIC is dependent on endogenous fibrinolysis
breaking down the disseminated thrombi. This process will be
inhibited by tranexamic acid, which is an anti-fibrinolytic, hence
tranexamic acid should not be used in COVID-associated DIC.
o Manage bleeding with blood product replacement as per managing major
bleeding as above i.e. if PT/INR or APTT ratios are greater than 1.5 then

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